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PUERPERAL 



CONVULSIONS, 



BY 



C. A. LINDSLEY, M. D. 



READ BEFORE THE 



eto Mint Count)} Utrtal Stonrtn, 



APRIL, 185 8. 



PUBLISHED BY ORDER OP THE CONNECTICUT MEDICAL SOCIETY, MAY 27, 1858. 



HARTFORD: 

PRESS OF CASE, LOCKWOOD AND COMPANY. 

M.DCCC.LVIII. 



YALE 
MEDICAL LIBRARY 




HISTORICAL 
LIBRARY 



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/ 

PUERPERAL CONVULSIONS. 

Dissertation read before the New Haven County Medical Society, 
April 8th, 1858. 

BY C. A. LINDSLEY, M. D., OF NEW IIAVEN. 



Mr. President and Gentlemen : — Perhaps our profession are 
not called to contend with any other disease, so formidable in its 
character, respecting which the best authors agree so exactly in the 
treatment. With scarcely a dissenting voice the grand chief remedy 
is venesection, — copious depletion, almost without reservation. 

Dr. P. Churchill says : " The first thing to be done is to take 
away blood from the arm or temporal artery largely ; if the paroxysms 
continue, this may be repeated." 

Dr. Copland, in his Dictionary of Medicine, in the article on Puer- 
peral Convulsions, observes : " Depletion may be carried further in 
those states of the disease which assume the character of eclampsia, 
or which are attended by great fullness about the head, or stertorous 
breathing, than in almost any other malady." 

Dr. Cazeaux remarks : " At the head of the list of curative means 
we must place sanguineous emissions, which have been resorted to 
under every form. To these, therefore, we must first have recourse." 

In like manner, Dr. Rigby, Dr. Eamsbotham, Dr. Meigs, — in fact 
almost every authority, — recommend free depletion. The inference 
naturally drawn from this fact would be that the etiology and pathology 
must be as well understood, and the lesions of the disease as 
uniform, as the treatment recommended. An inference, however, 
that would be far, very far from the truth. 

Indeed, the utmost confusion prevails among these same authors 
concerning everything else beside the treatment. 

To illustrate, I give some quotations in reference to the causes, 
from several contemporary y^rjters who will be recognized as authority 

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X br. F. H. Eanisbotham say* : " The most usual proximate cause 
is probably pressure on the brain ; this pressure being sometimes 
produced by the rupture of a bloodvessel sometimes, by serous ex&- • 
dation into the ventricles or between the membranes ; sometimes, and 
by far the most frequently, by simple congestion of the cerebral vessels 
themselves : as to the remote causes the subject is at best but unsatis- 
factory and little understood." 

Dr. Rigby remarks that: "The exciting cause of eclampsia par- 
turicntium is the irritation arising from the presence of the child in 
the uterus or passages, or from a state of irritation thus produced 
continuing to exist after labor. The predisposing causes are general 
plethora ; the pressure of the gravid uterus upon the abdominal aorta ; 
the contractions of that organ during labor; constipation; deranged 
bowels ; retention of urine ; previous injuries of the head, or cerebral 
disease ; and much mental excitement." 

Dr. F. Churchill declares : " It is exceedingly difficult to state 
anything very definite as to the cause of puerperal convulsions.'' 

Dr. Locock asserts that: "The immediate causes of puerperal 
convulsions are often very obscure. They appear sometimes to 
depend on a loaded state of the vessels of the brain; at other times 
the braiu appears to be influenced by distant irritation, either in the 
uterus, or in the digestive organs ; and again, in some cases puerperal 
convulsions are induced by a peculiar irritability of the nervous 
system." 

Dr. Collins says: "I conceive we are quite ignorant as yet of 
what the cause may be, nor could I ever find on dissection any appear- 
ance to enable me to even hazard an opinion on the subject." 

I might exhaust your patience, gentlemen, with cpiotations from the 
most eminent obstetric writers, exhibiting the discrepancy of opinion 
and doubt that exists concerning the causes of this dreadful malady. 

Any treatment founded upon no better basis than the guessings 
and surmises in the above quotations must be almost or altogether 
empirical. 

The therapeutics of any disease is philosophic and scientific just in 
proportion as it is the result of well understood pathology and etiology. 

In regard to puerperal convulsions, it remained for the masterly 
mind of Marshall Hall, the discoverer of the functions of the spinal 
marrow, to give the key to the solution of this obscure problem. He 
has demonstrated by repeated vivisections, which other observers have 
confirmed by the severest tests, that lesions of the encephalon induce 
paralysis only: whilst lesions of the medulla oblongata or spinalis 



induce convulsion or paralysis according to their severity. Hence it 
follows that the seat of convulsion of every form must be in the 
spinal column ; which opinion is supported by the experiments of 
Magendie, Schoeps, Flourens, Hertwig, and others. 

An interesting experiment performed upon a dog by Dr. Marshall 
Hall, proved that irritation of the brain produced no effect, while 
pinching the dura mater lining the cranium, to which are distributed 
branches of the fifth, excited convulsions ; so that the brain is actually 
inexcitor of spinal action, while the meninges are strongly excitor. 
The brain, therefore, has neither nerves of common sensation nor of 
excito-motion, although it is the sensorium commune. Pathology 
too gives support to the same idea, for we know that a tumor may 
exist in the brain without causing any cerebral or spinal symptoms, 
while a spicula of bone on the interior of the skull may occasion 
epilepsy. If the tumor does cause convulsion, it is by extension of 
irritation to the membranes, or by pressure on the medulla oblongata. 

From such facts as these, and many others, the inference is con- 
clusive that the nervous system is to be considered both physiologically 
and pathologically as two essentially distinct and separate organs, 
named by Dr. Marshall Hall the cerebral system and the excito- 
motor system. The last, with which we have more particularly to 
do, comprises the medulla spinalis and oblongata, with the corpora 
quadrigemina, forming together one distinct organ. Of this, Dr. M. 
Hall makes the following very comprehensive remark : " I believe 
that the whole order of spasmodic and convulsive diseases belongs to 
this, the excito-motory division of the nervous system, and that they 
can not be understood without a previous accurate knowledge of this 
system." 

But the authors above quoted agree, so far as they agree at all, in 
locating the disease in just the other division, the cerebral system, the 
brain. Forasmuch, however, as neither physiology nor accurate 
observation in pathology will sustain their theory, we must abandon 
it, or rather discover, if possible, the true relation of the cerebral 
symptoms to the disease. 

If it is the fact, as authors assert, that cerebral congestion is the 
cause of the attack, at what period of the labor ought we most confi- 
dently to expect the seizure ? Most assuredly, and for every reason, 
when the congestion is the greatest, — that is, in the second stage of 
labor, when the violent contraction of the uterus expels the blood from 
its parietes into the rest of the system ; when the powerful exertion of 
the voluntary muscles pours out a still larger quantity of blood into 



4 

the arteries and veins ; when the head of the foetus in the vagina has 
excited the reflex action of the expiratory muscles, causing with 
every pain, partial or entire closure of the glottis, interfering with the 
proper oxygenation of the blood in the lungs, obstructing its return 
from the luad, and often distending the veins of the head and neck 
until partial asphyxia occurs. Surely, if simple congestion can pro- 
duce convulsion, it is at such a time we should expect it. But such 
is not always the fact. The patient is often seized even before labor 
has commenced, or in the first stage when the circulation is undis- 
turbed, and there is as yet no excessive cerebral vascularity; and 
again, she may pass through the ordeal of the second stage unharmed, 
and be seized with the tits after the labor is concluded. 

Does not this fact alone sufficiently refute the generally received 
opinion that congestion of the brain is the chief cause? 

If congestion of the brain is the principal agent in the production of 
eclampsia, how can we explain this undisputed fact, that eclampsia 
occurs both before and after the most enormous congestion of that 
organ as frequently as during such congestion? Because engorge- 
ment of the vessels of the head is a constant symptom of the fit, it is 
not proof that it is the cause of the fit. Because after death from con- 
vulsion, sanguineous and serous effusion into the ventricles and 
between the membranes is found, it is not proof that such effusion was 
the cause of the convulsion. It is much more probable that both the 
engorgement and the effusion are in most cases results, — consequences 
of the disease, — and not the cause. Looking from another point of 
view, congestion of the brain is precisely what might be anticipated 
as an effect of the fit. During the attack almost every condition 
exists that would of the most inevitable necessity produce distension 
of the cerebral vessels and effusion. The fact is, gentlemen, observers 
have been looking through the wrong end of the glass ; they have 
seen every object distinctly, but they have misinterpreted them. 

In stating the case thus strongly, however, I do not wish to be 
understood as saying that congestion and effusion are never the cause 
of convulsion ; on the contrary, I believe that sometimes they are the 
cause. Now to illustrate exactly my idea I will suppose two instan- 
ces. If during the fierce exertions of the propulsive stage of labor, 
rupture of a blood-vessel occurs, producing by the effusion counter- 
pressure upon the medulla oblongata, and as a consequence convul- 
sions, the cause must undoubtedly be ascribed to the effusion. But if 
the patient is thrown into convulsion by irritation of the os uteri, and 
during the fit, rupture of a blood-vessel occurs with effusion into the 




brain, although after death precisely the same amount of coagula is 
found, and even in the same locality, the diagnosis of the two cases is 
vastly different. In the first case the coagula must be considered the 
cause, in the second only the effect, of the disease. I find a case in 
my note-book interesting in this connection, as illustrating some of 
the above remarks. It is as follows : 

August 12th, 1855, 1 was called early in the morning to see Mrs. S., 
forty years of age, about to be confined with her tenth child. Her trav- 
ail was tedious during the day, but in the evening the pains became 
more energetic, and about nine o'clock P. M. she was delivered of a 
healthy child, attended with considerable though not excessive hem- 
orrhage. Nothing unusual occurred for more than a week, excepting 
a headache, which she said she had suffered during the last twelve 
months. As she said that her former attendants had told her it was 
neuralgic, and as it was not unusually severe, I did not investigate it 
nor prescribe especially for it. Her lochia continued about ten days in 
normal quantity and color. Her milk began to be secreted on the third 
day, but not so abundant as usual, and gradually diminished. On the 
22d, ten days after confinement, her family congratulated themselves on 
her improvementbecause she slept quietly and did not complain of head- 
ache ; but in the evening they became alarmed, because they discovered 
she could talk only with difficulty, and that her right arm was partially 
paralyzed. I was immediately called, and found her with almost com- 
plete facial palsy upon the right side, and scarcely able to raise the 
right hand to her face; her leg was not as yet affected. Her speech 
was imperfect, but her mind was clear. These symptoms increased, 
attended with slight convulsive action gradually growing more violent, 
until the next day between eleven and twelve o'clock, when she died. 

Post Mort., twenty-four hours after death, thorax and abdomen 
entirely normal. Calvarium was very thick ; on removing it found 
considerable serum ; blood-vessels all filled with blood. Upon laying 
open the cerebrum upon the left side, found a coagulum of blood near 
the centre as large as a goose egg. The structure of the brain was 
softened all about it for more than half an inch. There was evidence 
that the coagulum had existed a considerable length of time ; in all prob- 
ability had been there prior to her confinement. It is rare indeed that 
we meet with an instance in which a protracted and tedious labor is 
combined with such extensive lesion of the brain, — neither condition 
appearing to have any relation to the other. It is very instructive, 
too, illustrating fully the fact that so long as the disease is confined to 
the brain, convulsion can not be a consequence, even though attended 



6 

by the exciting cause of severe labor. It is of interest, too, in regard 
to the teachings of the old authors. According to them, here was 
every condition fulfilled requisite for the development of puerperal 
convulsions. But instead, she suffered a severe and protracted labor 
without any symptoms of them. On the contrary, the first indication 
of disease of the nervous system was paralysis, the legitimate effect of 
disease of the brain. And not until the increase of the cranial con- 
tents produced counter pressure upon the upper portion of the inter- 
vertebral system did convulsions occur. 

Seeing, then, the error of locating the disease in the brain, and 
adopting the theory of Marshall Hall that the excito-motory division 
of the nervous system is the true and only centre of convulsive action, 
it follows that the causes must be such as act immediately upon that 
central organ, or such as are transmitted to it from the extremities of 
the excito-motor nerves. The first class he denominates the centric 
causes, the other the eccentric. 

Among the centric causes, or those which act directly upon the 
spinal marrow, may be mentioned, alteration in the quantity, or in 
the quality of the blood. And there is also good reason for supposing 
that sudden emotion is direct in its influence upon the spinal centre, 
although the anatomical mechanism of its operation is as yet wholly 
inexplicable. 

That an excessive quantity of blood in the vessels of the spinal 
column is a powerful excitant of that organ, scarcely admits of doubt. 
The pathological effect of active congestion is almost always stimu- 
lant, and the full distension of the vessels, whether producing rupture 
or not, would create pressure, which incontestiblc experiment has 
proved to be an infallible excitant of spinal action. In like manner, 
congestion or extravasation within the cranium, by filling a portion of 
the space within this unyielding bony cavity, creates a counter pres- 
sure upon the medulla oblongata and the superior extremity of the 
intervertebral column, and again we have convulsion, the active 
symptom of spinal irritation. So, too, the growth of a tumor, or any 
disease capable of producing internal pressure within the brain, would 
cause the same result. If, then, plethora is a spinal irritant, on the 
other hand, the opposite condition, spinal anaemia, is an equally power- 
ful irritant. We see constant illustrations of this in deaths from 
hemorrhage, which are generally attended by convulsions ; and animals 
bled to death either in experiments or at the shambles always have 
convulsions. It appears, then, that any great alteration in the quantity 
of the blood, whether it be an excess or deficiency, is a cause of 



convulsion. This is a significant fact in reference to treatment. 
Recent and more accurate observation goes to show that a change in 
the quality of the. blood is an important element in the etiology of this 
disease. 

Pregnancy, in its progress bringing into action new functions, and 
affecting temporarily the whole economy of the system, creates in 
general a tendency to an altered condition of the vital fluid in the 
relative proportion of its elements. This alteration consists essentially 
in a diminution of the solid constituents. Sometimes the corpuscles 
are diminished, producing chlorosis and its attendant train ; some- 
times the albumen is eliminated : indeed, this latter change is so con- 
stantly true of the pregnant woman that it may almost be considered 
the physiological condition. Now if to this tendency are added the 
prostrating influences of deficient nutrition, destitution, cold and damp- 
ness, combined with the depressing passions, this seemingly physio- 
logical state passes readily and gradually into the pathological, and 
there is established the incipient stage of that disease which in its full 
development is granular nephritis, or Bright's disease. The vigilance 
of modern researches has detected what escaped the notice of the 
older pathologists, that in almost every case of true eclampsia, the 
blood is found deficient in albumen, while the urine is highly charged 
with it. 

" The presence of albumen in the urine of eclamptic women," says 
Cazeaux, " is a very remarkable coincidence, which is at present well 
determined by the observations of many physicians ; and it evidently 
seems to be the dominant fact in the etiology of puerperal convul- 
sions.'' Albuminurea being so constant in cases of eclampsia, the 
inference is irresistible that there is a relation more or less intimate of 
cause and effect between the two facts. For since attention has been 
fixed upon this point, convulsions have occurred in those only who 
have been affected with albuminurea. The exceptional cases are 
rare, if any. 

It is an old remark that oedema of the face and neck is a frequent 
premonitory sign of the attack ; and it is now a well established fact 
that this general cedema of the upper extremities is almost always 
connected with an alteration of the urinary secretion, and is one of 
the most constant symptoms of albuminurea. 

Nor is the hypothesis, that the diminution of albumen in the blood 
and albuminurea are necessary conditions of eclampsia, at all incon- 
sistent with the fact that seven-eighths of the cases of eclampsia have 
occurred in primiparous women. Because, in first pregnancies, the 



8 

greater resistance of the abdominal parietes causes the uterus to be 
more strongly applied to the posterior walls of the abdomen, eom- 
pressing the venal vein, causing congestion of the kidneys, obstructing 
the venous circulation and forming a mechanical obstacle to the regu- 
lar fulfillment of the functions of the neighboring organs, and thus 
bringing about the very organic conditions most favorable to the pro- 
duction of albuminurea. So, also, women affected with rachitis are 
more liable to convulsions, because of their deformity and the limited 
space within the pelvis. The necessary compression that attends the 
development of the uterus disposes to the same result. Hence it 
would appear from constant concurrence of albuminurea and eclamp- 
sia, that the altered state of the blood (which is a necessary conse- 
quence of l<in^ continued albuminurea) is a direct irritant of the 
spinal axis, or, if nut the sob- excitant of the spasm, renders that 
< . i ■ _r : 1 1 1 more Busceptible to the influences which reach it from other 
sources. 

It is not the design of this paper to enter into all the minor causes 
which act directly upon the central organ, and we will pass at once 
to the consideration of the more important remedies indicated in the 
removal of the causes mentioned. 

First on the list, after the example of all writers, I will speak of 
blood-letting. Blood-letting is in the great majority of cases most 
urgently indicated, not only to relieve the blood-vessels of the brain, 
which would seem to be the chief reason urged by authors above 
quoted, but also and especially because of its sedative action on the 
spinal system, which is the true seat of puerperal convulsion. I say 
the majority of cases, because there is almost always great vascular 
fullness, a plethoric condition of the system, and it is in this condition 
that blood-letting is the most positive and decided sedative of spinal 
action that we possess. And this is a point which should be most 
distinctly understood, that blood-letting acts in two ways, one curative 
in its effects on the spinal column, the other preservative in relation 
to the brain. 

In fullness of the vascular system, then, blood-letting beside dimin- 
ishing the impressibility of the central organ by rendering it less sus- 
ceptible to incident irritation, relieves also the surcharged condition 
of the cerebral vessels, obviates partially the immense pressure to 
which those vessels are subjected during the fits, diminishes the 
danger of rupture and effusion, and removes the counter pressure upon 
the medulla oblongata. It is because of the»e prompt and marked 
effects that the remedy has been so uniformly recommended and 



practiced in all cases. But while it is often a sufficient remedy for 
simple convulsions, depending on a turgid state of the circulation, 
great discrimination and careful judgment are requisite, not only in 
limiting it within safe bounds, and in detecting indications for other 
treatment, but also for determining whether in some cases it will not 
be injurious instead of curative. If blood-letting is indicated for the 
reasons which have been mentioned, it is perfectly evident that it is 
contra-indicated, and would prove extremely dangerous, in cases where 
those reasons do not exist ; that is, in delicate anaemic women, 
copious depletion would be an additional cause of convulsion, because, 
as has been shown, deficiency of blood is an irritant of spinal action. 
It is, however, too much the fact that the constant teaching of the 
books, combined with the absence of positive knowledge of the true 
seat and etiology of the disease, has led to the blind and indiscrimi- 
nate routine of bleeding every poor patient perchance to, — I had 
almost said to death, — or perchance to life, as chance alone decides, 
the chief guide of practice being the continuation or cessation of the fits. 

Says Dr. Meigs : " If I were treating a woman in labor seized 
with the true puerperal convulsion I should certainly bleed her, pro- 
vided the convulsion did not cease before I could effect my purpose, 
and should I in such case open the vein, I should surely allow the 
stream to flow as long as any convulsive innervations were left 
unquelled. Provided they should return again, I should bleed her a 
second time, and allow the blood to flow until the spasmodic and 
convulsive phenomena should have again disappeared." 

Even so judicious a practitioner as Dr. Robert Gooch declares that 
" bleeding is our sheet-anchor in whatever class of patients the disease 
may occur ; and that he never had a patient die of the disease where 
bleeding had been boldly employed." 

Bleed is the rule, absolute and imperative, — bleed, — bleed, — no 
matter what the condition of the patient. No effort is directed to 
discover any cause of spinal irritation, which should be removed ; 
the patient has fits ; therefore bleed her. No matter if the stomach 
is loaded with indigestible food, or the bowels with hardened fceees. 
No matter if the bladder is distended to bursting. No matter what 
the state of the uterus, or what the condition of the vascular system, 
the rule is still arbitrary, — bleed boldly and fearlessly. Now this is rank 
and rash empiricism, and in the present state of physiological knowl- 
edge, inexcusable. And yet there can be no doubt that many prac- 
titioners, influenced by the teachings of the books, have carried 
depletion to a fatal excess, and even practiced it when it ought to have 
2 



10 

been altogether avoided. It can not be questioned that if carried 
beyond proper limits, blood-letting is itself a cause of convulsions^ 
Dr. Marshall Hall says, convulsion from loss of blood constitutes one 
species of puerperal convulsion, and should be accurately distinguished 
from other forms of this affection, arising from intestinal or uterine 
irritation, and an immediate disease of the head. (On Blood-letting, 
p. 17.) 

It would appear, then, that after the circulation is reduced, either by 
proper depletion or from other causes, to somewhat below par, blood- 
letting acts no longer as a sedative, but becomes itself a most certain 
irritant of the spinal system. The continuance of convulsions, 
therefore, is not a reliable indication for further bleeding ; but the 
state of the circulation in the interval of the tits, is the only proper 
criterion, regard being had to the different effects of an engorged and 
an empty state of the spinal vessels. 

The dilatation of the glottis, by exciting an inspiration, although 
apparently trivial, is of no mean importance in its effect. Dr. M. 
Hall thinks that in all cases of true convulsion the glottis is 
wholly or partially closed, the effect of which is to increase both the 
cerebral and spinal congestion. There are several cases recorded 
where this simple expedient has prevented the convulsions. It is well 
known that the sudden shock of a dash of cold water in the face, by 
its reflex action upon the respiratory muscles will cause an involun- 
tary inspiration, thus opening the glottis and relieving congestion. 
Denman gives the history of a lady, whose every pain was attended 
by a convulsion ; but, by sprinkling the face with cold water at the 
beginning of each contraction, he prevented the convulsions during 
the rest of the labor. So simple a remedy can do no harm, and even 
if it does not prevent a convulsion it takes off a great amount of vas- 
cular pressure from the nervous centres, and lessens the amount of 
venous blood in the system every time it uncloses the glottis. 

Among other remedies which are directly sedative to the nervous 
centres, an important one is the application of cold. When applied 
in a continued stream to the head, it lessens the distended state of 
the cerebral circulation, and relieves the counter pressure upon the 
inter-cranial portion of the spinal system. In the form of the douche 
it would tend to excite an inspiration and thus dilate the glottis. 
When applied along the spine it should be continuous, because the 
intermittent application excites instead of allays spinal action. 

Of the narcotics, I shall only speak of opium. This drug has been 
more used than any other medicament, and yet authors exhibit the 



11 

greatest discrepancy of opinion as to the effect of it. The point of 
most importance in this connection is, if it be an irritant or a sedative 
of the excito-motory division of the nervous system. The heroic 
doses that have been given time and again in tetanus and hydropho- 
bia, the purest forms of morbid spinal action, without in the least 
degree allaying spasm, would seem to prove that it is not a sedative of 
that portion of the nervous system. And there is reason to believe 
that it is generally a direct irritant. In poisoning by opium, especially 
children, convulsions occur as one of its most common toxicological 
effects. In amphibious animals it is a powerful spinal stimulant. 
When they are narcotized the slightest irritation of the surface pro- 
duces universal convulsions, showing that narcotism exalts the excito- 
motor system to the most intense degree. Although it is evident that 
these effects are not so marked in man. Dr. Tyler Smith has written 
so well and clearly on this point, that I shall be excused for using his 
words. He says : " Some striking distinctions must be made respect- 
ing the administration of opium under different circumstances, particu- 
larly in puerperal convulsions. If a dose of opium be given in this 
disease in a full state of the circulation, before bleeding, there is an 
aggravation of the disorder ; while if it be in puerperal convulsions in 
an ancemic subject, or after excessive depletion, it is of great ser- 
vice. If in a case of convulsions, opium be given at the commence- 
ment, it is dangerous in its effects ; but the same medicine is frequently 
valuable in the advanced stage of the same case when the vascular 
system has been powerfully depleted. Thus it would appear evident 
that in convulsions with a full state of the circulation, opium is a 
stimulant of the spinal marrow, while in convulsions with anaemia it 
is distinctly sedative. It is certainly an important point in practice 
that the effects of opium in puerperal convulsions depend on the state 
of the circulation ; that in plethora or inflammatory conditions it is 
always dangerous, while in anosmia and debility it may always be 
used beneficially." 

My paper has already reached such a length that I will pass over 
other remedial agents, acting upon the central organ, to remove 
centric causes and briefly allude to the eccentric causes of the disease 
and the remedial indications connected with them. These causes are 
such as to take effect upon the peripheral extremities of the incident 
excitor nerves, and of course relate to organs at a distance from the 
nervous centres,— such as the stomach, the rectum, the bladder, the 
uterus and the vagina. The irritation in these cases being transmit- 
ted to the central organ, and causing convulsion by reflex action. 



12 

Numerous instances attest the fact that large accumulations in the 
stomach or intestines, whether of food, or feces, or worms, or foreign 
bodies, excite the disease in this way. The removal of these offend- 
ing substances is obviously demanded where they are known to exist. 
Dut the manner in which it should l>e accomplished is important. 
There can he but little difference between irritant drugs and irritant 
feces, and yel the most drastic purgatives are unceremoniously 

exhibited, which t iften is only to change one cause (if irritation for 

another. The prolonged effect of powerful cathartics upon the sur- 
face of the intestines already irritated to the highest intensity, must 
be mi) thing but favorable. It is but fair to presume that copious 
injections of simple water, would be quite as effectual and vastly 
safer, inasmuch n> they are inure rapid in their etl'eet and do not 
remain to fret the bowels after their mission is accomplished. Their 
action might be assisted if necessary by the addition of castor oil or 
turpentine. If indigestible food, or an overloaded stomach excite the 

fits, an emetic of the sulphate of zinc should he administered. If the 
subject however i.-- plethoric, venesection should precede the emetic, 
on account of the increased distension of the cerebral vessels in the 
effort of vomiting. 

Mr. Vines mentions a case of convulsions which after resisting (or 
two days all the usual remedies, including delivery, ceased immedi- 
ately upon withdrawing from the bladder five and a half pints of 
turbid and highly ammoniacal urine. This case shows the necessity 
of attention to that organ. But it is in the uterus and uterine passa- 
ges that rellex irritation acts most energetically and with the greatest 
intensity. The discussion of this particular branch of the subject is 
sufficient of itself for a lengthy dissertation. The various questions 
of treatment which arise.in different conditions of that viscus and its 
contents, relating to delivery, and the preferable methods of it, are 
deeply interesting, but the limits of this paper will not permit me to 
enter upon them. I will content myself with giving a general princi- 
ple, in regard to the propriety of assisting delivery, based upon the 
theory of reflex action. The rule is this : if the condition of the mother 
is perilous, and the continuance of the child in the uterus or passages is 
productive of more irritation than would be occasioned by manual or 
instrumental interference, then artificial delivery should be resorted to. 
I am aware that this rule is indefinite because the conditions upon 
which it rests are only approximations. The amount of irritation in 
either case not being constant quantities, an accurate comparison can 
not be made. Nor is it possible to lay down a definite rule applicable 



13 

to all cases, the peculiarities of each case being such that no one rule 
can cover them. 

Of the prophylactic treatment of this disease, gentlemen, I have 
made no mention. It can scarcely be doubted that there is some 
alteration of the general economy, which predisposes the puerperal 
patient to eclampsia, and without which the various exciting causes 
which I have named would fail of that result. But the pathology of 
this stage of the disease is so barren of facts that little that is definite 
and positive can be said about it. If the constant investigations which 
are illuminating this department of the subject should confirm the 
theory respecting albuminurea, it may possibly lead to the discovery 
of some treatment which in that early stage may be more successful 
than it has proved in other conditions of albuminurea. It would 
be a boon indeed to obstetrical science, if a disease so terrible and 
disastrous could be detected in its approaches in time for prophy- 
lactic measures to be used with certainty. 

If, gentlemen, in the cursory review of this subject, I have suc- 
ceeded in arousing afresh your interest, and stimulated you to seek 
from better sources more light upon it, I have done all I aimed to do ; 
and have thereby perhaps contributed my mite to the cause of 
humanity, by putting you in the way of better preparation to contend 
with this formidable enemy which commits its ravages only upon the 
fairest of creation. 



C. A. LINDSLEY. 



New Haven, May, 1858. 




Accession no. 

Author Lindsley: 
°uerperal 
convulsions. 1858.